Clinical Presentation of Erysipelas
Erysipelas presents as a rapidly spreading, well-demarcated area of intense erythema, edema, warmth, and tenderness with a characteristic raised border, often accompanied by systemic symptoms including fever that may precede skin manifestations. 1, 2
Characteristic Skin Findings
The hallmark features that distinguish erysipelas from other skin infections include:
- Sharply demarcated, raised borders that clearly separate affected from unaffected skin, creating a distinct edge 1, 2
- "Peau d'orange" (orange peel) appearance caused by superficial cutaneous edema surrounding hair follicles, which remain tethered to the underlying dermis creating characteristic skin dimpling 1, 3
- Intense erythema with associated swelling, tenderness, and warmth that spreads rapidly over hours to days 1, 2
- Vesicles, bullae, and cutaneous hemorrhage (petechiae or ecchymoses) may develop in more severe cases 1, 2
Anatomic Distribution
- Lower extremities (legs) are affected in 85-95% of cases, making this the most common site 2, 3, 4
- Facial involvement is the second most common presentation 1, 3
- Upper thigh and arm involvement occurs less frequently 3
Systemic Manifestations
The systemic features often precede or accompany the skin findings:
- Fever is typically present and may occur hours before skin abnormalities appear 1, 2, 3
- Sudden onset with acute symptoms including chills and shivering 2, 3, 4
- Tachycardia, confusion, and hypotension may develop in severe cases 1
- Leukocytosis with neutrophil predominance (median ~12 × 10⁹/L with 75% neutrophils) 4
Associated Lymphatic Findings
- Lymphangitis (visible red streaking along lymphatic channels) may be present 1, 2
- Regional lymphadenopathy with tender, enlarged lymph nodes draining the affected area 1, 2, 3
Common Entry Points and Predisposing Factors
Look specifically for these portals of bacterial entry:
- Athlete's foot (tinea pedis) with fissured toe webs is the most common entry point 3
- Minor trauma, even clinically inapparent skin breaks 2
- Preexisting skin conditions: impetigo, ecthyma, eczema, or other inflammatory dermatoses 2
- Venous insufficiency or previous lymphatic disruption from surgery (saphenous venectomy, lymph node dissection) 2, 5
Critical Diagnostic Pitfall
Do not confuse erysipelas with purulent infections (abscesses, furuncles, septic bursitis). The term "cellulitis" or "erysipelas" should only be used for diffuse, spreading infections without pus collections, as this distinction determines whether drainage or antibiotics alone is the primary treatment. 1, 6